Polyorgan insufficiency – simultaneous or consecutive defeat of several systems with initial prevalence of symptoms of refusal of one of them. The defining signs are cyanosis, short wind, hypostases, an anury, hypotonia, a state of shock. The diagnosis is established on the basis of a clinical picture, data of laboratory and hardware inspection. Specific treatment: support of breath and warm activity, stabilization of haemo dynamics, elimination of a pathogenetic factor (fight against an infection, correction of metabolic violations, restoration of OTsK, normalization of a hemostasis), artificial and natural detoxication.
Polyorgan insufficiency (PON) – the pathology arising mainly at patients of intensive care units. As independent nosological unit was for the first time described in 1973, before was considered as a combination of two and the violations which were any more not connected among themselves. Frequency of occurrence makes about 5-10% of total of patients. Mortality in this group comes nearer 60%. More often the patients having failures in work of three bodies perish. The state develops for 3-5 days after successful restoration of warm activity, at the severe combined injuries, poisonings, endotoxicoses. The syndrome of the system inflammatory answer is the cornerstone of development.
Reasons of polyorgan insufficiency
PON results from the pathological changes happening in an organism after a stop and the subsequent recovery of work of heart. Besides, it can be formed against the background of a heavy polytrauma, infectious and toxic shock, sepsis, peritonitis. Develops more often if one of the bodies involved in process was struck with chronic pathology earlier or is changed as a result of influence of primary factor (a lung contusion at road accident, decrease in sokratitelny ability of a myocardium at a sharp coronary syndrome). Include in number of etiofaktor:
- Influence of mediators of an inflammation. In response to damage of a cage vascular an endoteliya begin to synthesize biologically active agents: interleykina, tsitokina, nitrogen oxide, interferona, tumoralny nekrotiziruyushchy factor. Under the influence of these components there is a change of permeability of a vascular wall, tone of blood system, work of makrofagalny immunity. In the conditions of physiological violations mediators of an inflammation make excessive impact, lead to development of hypostases, the expressed dilatation or a konstriktion of vessels, emergence of inflammatory reaction.
- Microcirculator failures. At extensive injuries there is blood sequestration to formation of a gipovolemiya. It becomes the reason of reduction of warm emission, formation of microblood clots, deteriorations in perfusion in fabrics and bodies, relative ischemia. In development of PON a part is also played by the reperfusion mechanism at which there are changes connected with restoration of an adequate blood-groove (an oxygen, calcic, ionic paradox).
- Infectious and septic influence. It Nablyudtsya both at volume bacterial processes, and at any other serious illness. In the first case sepsis becomes result of hit of flora in blood from the inflammation center. In the second – microorganisms get into a system blood-groove from intestines which permeability of a wall increases at exhaustion. There is a stimulation of development of tsitokin and development of system inflammatory reaction.
- Phenomenon of "double blow". It is caused by the therapeutic impact on the victim leading to aggravation of PON. Active infusion of plazmozameshchayushchy solutions is the reason of a reperfusion syndrome, the massive antibacterial influence directed to fight against sepsis strengthens toxic load of systems of an ekskretion. All this negatively influences weight of a condition of the patient.
Polyorgan destruction has several mechanisms of development, ischemic damage of bodies is basic of which. A part of cages dies off, the others pass into the anaerobic mode of glycolysis. The main damages arise at restoration of a blood-groove. During this period a large number of the free radicals causing perikisny oxidation of fabrics is formed. The second pathogenetic mechanism is the intensive tromboobrazovaniye at an initial stage of the DVS-syndrome. The formed mikroembola break passability of capillary network that strengthens ischemia.
Hypostases as a result of the increased permeability of vessels lead to accumulation of liquid in an abdominal cavity, strengthening of an intra abdominal compression. There is a mechanical compression of bodies of a stomach, raising of a diaphragm to restriction of mobility of lungs. Growth of intra chest pressure, reduction of working space of heart is noted. Outflow of blood from a brain is broken. The central nervous system is involved in process, cerebral hypostasis with the advent of neurologic symptomatology develops.
Division of PON into groups is made by results of assessment of activity of bodies and systems, the general condition of the patient. The scale of Apache II or D. Marshall created in 1995 especially for work with the patients suffering from polyorgan insufficiency can be for this purpose used. In practice A. L. Levitte's method presented in 2000 is more urgent. According to it, each of systems can be in the compensated, subcompensated or dekompensirovanny state. Polyorgan insufficiency is defined as heavy at a decompensation of two systems as extremely heavy – at considerable changes in three bodies. Assessment is carried out separately on each body
- Compensation. The organism functions with insignificant aberrations, full refusal of any system does not come. Changes quickly progress. In fact, the compensatory stage belongs not to PON per se, and to its harbingers. Correction of a state at this stage allows to prevent heavy ischemic damage of fabrics. Duration of a stage depends on an initial condition of the patient and can make from several hours to 3-5 days.
- Subcompensation. The moderate changes demanding medicamentous correction. The patients who are in this stage quite often need introduction of rather small doses of inotropny means, auxiliary respiratory support, single reception of diuretic medicines. In the absence of the help duration of the subcompensatory period reaches 1 days.
- Decompensation. Heavy changes in structure of bodies, full or partial violation of their function. There are signs of defeat of several systems. The patient is in critical condition. Intensive therapy with use of hi-tech techniques of maintenance of activity is required. IVL, infusion of pressor amines, a detoxication with use of " devices an artificial kidney is shown".
Symptoms of polyorgan insufficiency
The clinical picture depends on existence of defeat of these or those structures. Usually to the forefront there are signs of changes from respiratory system. Short wind, diffusion cyanosis, inclusion of auxiliary muscles in process of a breath, perspiration, psychomotor excitement is noted. The patients capable to move independently, hold the compelled sitting position with an emphasis hands in a bed. Later activity is replaced by block, consciousness oppression.
Polyorgan insufficiency with damage of heart is shown by zagrudinny pains, instability of haemo dynamics, accumulation of liquid in soft fabrics due to strengthening of proliferation of plasma through a vascular wall. There can be a hypostasis of lungs which is followed by emergence of pinkish foam from a mouth. Compensatory tachycardia to 180 . / the min., later replaced by bradycardia with an urezheniye ChSS to 40 and below comes to light. At a terminal stage there is a decrease in sensitivity to inotropny means and alpha .
At a kidney and hepatic kind of a disease diuresis volume considerably decreases. Then there is an anury demanding carrying out a hemodialysis. The hypoglycemia involving consciousness violations is found. At the patient ascites, dyspepsia, proteinaceous hypostases develops. Skin and mucous membranes turn yellow, hemorrhagic rash is possible. In several hours or days symptoms of hepatic encephalopathy are found: the patient does not realize the actions, does not understand where he is that happens to him.
Damages of a GIT are characterized by signs of the obstruction caused by a mechanical sdavleniye of intestines. Pain, swelling, asymmetry of a forward belly wall, a delay of a chair and gases, vomiting is defined. There is no tolerance to feeding. Development of a stressful ulcer and an intestinal gemorragiya which is shown by decrease in the Hb level, pallor of the patient, falling HELL, emergence or strengthening of DVS of a syndrome at massive blood loss is possible.
At successful knocking over polyorgan defeat can come to the end with development of the delayed diseases. At 5% of the patients who repeatedly asked for the help in MPI, diagnose a chronic renal failure, about 2% of patients test symptoms of coronary heart disease or have HSN signs. Pulmonary changes are noted in 3% of cases. In the sharp period a complication is fibrillation of ventricles against the background of toxic damage of a myocardium and tachycardia with ChSS is higher 160-180/min. Damage of the carrying-out system of heart with formation of CA or AB of blockade is possible. Brain ischemia quite often leads to decrease in mental capacities, encephalopathy, paresis, paralyzes.
Diagnostics is performed by results of clinical, laboratory and tool inspection. The intensivist has to supervise patients, however can perform primary inspection and establish the preliminary diagnosis for the direction of the patient in profile office the doctor of any specialty, including the employee of crew of SMP. Differential diagnostics is carried out with the combined pathology of several systems of an organism, the etiologicheska which is not connected with mechanisms of development of the considered disease. The full program of inspection includes:
- Fizikalny survey. During consultation the expert reveals characteristic external signs of defeat of this or that body, defines existence of subjective complaints. In most cases symptoms of violations of haemo dynamics, warm activity and breath, metabolic changes are found.
- Laboratory diagnostics. In analyses decrease in level of hemoglobin to 60-80 g/l, falling of glucose to 2,5 mmol/l, growth of nuclear heating plant, ALT more than twice from normal indicators, increase in content of bilirubin ≥ 30 mmol/litre is noted. PaO2 is in limits 64-50, PaCO2 – 56-90 mm of mercury., pH changes in the sour party (≤ 7.3).
- Hardware inspection. The main method – continuous monitoring of vital signs. Indicators often are in the following borders: GARDEN ≤ 50 mm of mercury. (in the absence of medicamentous support), ChSS ≥ 180 or ≤ 40 in a minute. Central venous pressure ≥ 14 mm or negative. ChDD ≥ 5 or ≤ 50 (without IVL and oxygenotherapy). When carrying out a X-ray analysis of lungs blackouts are visualized, when performing ultrasonography of an abdominal cavity the level of free liquid comes to light.
Treatment of polyorgan insufficiency
Therapy is directed to restoration of OTsK, normalization of rheological properties of blood, support of vital functions, prevention of consequences of the delayed character. Polyorgan insufficiency has to be stopped at compensation stage, it increases probability of a complete recovery. The following medical impacts on the patient are applied:
- All-regime actions: observance of the most strict bed rest, the round-the-clock observation with use of the anesteziologichesky cardiomonitor. Indicators of AD, ChSS, ChDD, a saturation, a warm rhythm are subject to control. Each 4 hours blood sampling on KShchS, daily – on biochemistry and the general analysis is made. For the prevention of trophic injury of skin full hygienic leaving is carried out, food is appointed according to the available violations (sparing, liquid, parenteral).
- Conservative treatment. Plentiful infusions of kristalloidny and colloidal solutions are shown. At hypotonia the dopamine is entered. At deficiency of factors of folding and existence of the DVS-syndrome the transfusion of freshly frozen plasma is necessary. The strengthened tromboobrazovaniye demands reception of acetilsalicylic acid, a kurantil, heparin. At the expressed symptomatology anti-mediator therapy is made by an ibuprofen, inhibitors of a factor of activation of platelets. Intravenous administration of steroid hormones, antibiotics is recommended.
- Surgical treatment. Carry an extracorporal detoxication to number of invasive procedures (haemo - and peritonealny dialysis). Open intervention can be required at full failure or a necrosis of internals (a liver, kidneys), and also at intestinal impassability. For removal of astsitichesky liquid carry out .
Forecast and prevention
Polyorgan insufficiency has a favorable outcome at an early initiation of treatment. In process of progressing of process in an organism the irreversible changes increasing risk of emergence of complications collect. The Dekompensirovanny form of a disease has the adverse forecast, in 60% of cases leads of the patient to death. Prevention consists in prevention of PON. It is necessary to stop the infection centers, at volume injuries to begin massive infusion at a pre-hospital stage, in due time to eliminate the available violations of haemo dynamics and a warm rhythm. An important point is control of a diuresis of the patient who is on treatment in ORIT. The difference between the used and emitted liquid should not make more than 100-200 ml a day.
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